Painful Diabetic Neuropathy — RACP Adult Medicine MCQ

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EasyEndocrinology & DiabetesPainful Diabetic NeuropathyRACP Adult Medicine

A 55-year-old man with type 2 diabetes and peripheral neuropathy develops severe burning pain in his feet bilaterally. Paracetamol provides no relief. What is the first-line pharmacological treatment for painful diabetic neuropathy?

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Correct answer: D — Pregabalin or duloxetine

First-line agents for painful diabetic peripheral neuropathy are pregabalin (start 75 mg BD, titrate to 300 mg BD), duloxetine (60 mg daily), or amitriptyline (10–75 mg nocte). The choice depends on comorbidities and side-effect profile: pregabalin for patients with anxiety; duloxetine for depression; amitriptyline is cheap but has anticholinergic effects (avoid in elderly). Opioids are not first-line due to dependency risk. Gabapentin is an alternative. Topical capsaicin (8% patch) is an adjunct.

Reference: eTG – 2025 – Neurology; ADS – 2024 – Diabetic Complications Management